Request to Debit Hours Template (25AN)

Request for genIC Approval

CDC/ATSDR Direct Reading Methodologies, Sensors, and Robotics Technology Assessment in Lab/Simulator-based Settings

0920-1441

CIO: The Centers for Disease Control and Prevention (CDC), National Institute for Occupational Safety and Health (NIOSH)

PROJECT TITLE: Insert protocol title

PURPOSE AND USE OF COLLECTION:

Here insert a short paragraph specific to your information collection request.

DESCRIPTION OF RESPONDENTS:

Here insert 3-5 sentences that are specific to the respondents for your study.

CERTIFICATION:

I certify the following to be true:

1. The collection is voluntary.

2. The collection is low-burden for respondents and low-cost for the Federal Government.

3. The collection is non-controversial and does not raise issues of concern to other federal agencies.

4. Information gathered will not be used to substantially inform influential policy decisions.

5. The study is not intended to produce results that can be generalized beyond its scope.

Name: Project Officer Name

To assist review, please answer the following questions:

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? [ ] Yes [ ] No

2. If Yes, is the information that will be collected included in records that are subject to the Privacy Act of 1974? [ ] Yes [ ] No

3. If Applicable, has a System or Records Notice been published? [ ] Yes [ ] No

Right now, leave this blank until you consult with your ODIT Technical Services Manager (TSM).

Project Officers must get a Privacy Act determination from ODIT, who is responsible for completing this section.

Gifts or Payments:

Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants? [ ] Yes [ ] No

Provide a response for your study. If you exceed $40 per hour, provide evidence to support the increased incentive.

Insert 3-5 sentences describing your payment/reimbursement plan if "Yes" was checked.

BURDEN HOURS

This is the burden table for the entire generic package. If you are not collecting information using some instruments, delete those rows and add applicable rows as needed. Provide the number of respondents and burden hours for your study.

Category of Respondent	Form Name	Number of Respondents	Number of Responses per Respondent	Average Hours Per Response	Total Response Burden (Hours)
Members of the general public who represent a variety of industrial sectors.	Informed consent
Members of the general public who represent a variety of industrial sectors.	Demographics standardized survey with decision logic allowing some questions to be omitted
Members of the general public who represent a variety of industrial sectors.	Perceptions-based survey instrument
Members of the general public who represent a variety of industrial sectors.	Physiological Monitoring: Heart rate, blood pressure, blood oxygen saturation, breathing rate, etc.
Total

FEDERAL COST: The estimated annual cost to the Federal government is $XXXXX

Complete a cost estimate for your study. Include the cost of paying the staff who are overseeing and conducting the study.

If you are conducting a focus group, survey, or plan to employ statistical methods, please provide answers to the following questions:

The selection of your targeted respondents

1. Do you have a customer list or something similar that defines the universe of potential respondents and do you have a sampling plan for selecting from this universe? [] Yes [ ] No

If the answer is yes, please provide a description of both below (or attach the sampling plan)? If the answer is no, please provide a description of how you plan to identify your potential group of respondents and how you will select them?

Regardless of answering yes or no, you will have to develop and provide a description of your sampling plan/how you plan to recruit. This may be a separate document.

Administration of the Instrument

1. How will you collect the information? (Check all that apply)

[ ] Web-based or other forms of Social Media

[ ] Telephone

[ ] In-person

[ ] Mail

[ ] Other, Explain

2. Will interviewers or facilitators be used? [ ] Yes [ ] No

Please make sure all instruments, instructions, and scripts are submitted with the request.

All content below is guidance. Do not fill out any information in the sections below. All information should appear above. Please review this guidance and make sure that your content is fully responsive.

Instructions for completing genIC Request for Approval

TITLE OF INFORMATION COLLECTION: Provide the name of the collection that is requested.

PURPOSE and USE: Provide a brief description of the purpose of this collection and how it will be used. If this is part of a larger study or effort, please include this in your explanation.

DESCRIPTION OF RESPONDENTS: Briefly describe the targeted group/groups for this collection.

CERTIFICATION: Please read the certification carefully. If you incorrectly certify, the collection will be returned as improperly submitted or it will be disapproved.

Personally Identifiable Information: Provide answers to the questions.

Gifts or Payments: If you answer yes to the question, please describe the incentive and provide a justification for the amount.

BURDEN HOURS:

Category of Respondents: Identify who you expect the respondents to be in terms of the following categories: (1) Individuals or Households; (2) Private Sector; (3) State, local, or tribal governments; or (4) Federal Government. Only one type of respondent can be selected.

Form: Provide the title of the information collection form.

No. of Respondents: Provide an estimate of the Number of respondents.

Participation Time: Provide an estimate of the amount of time required for a respondent to participate (e.g. fill out a survey or participate in a focus group).

Burden in Minutes: Multiply the Number of responses and the participation time and divide by 60.

FEDERAL COST: Estimate the annual cost to the Federal government for this collection.

If you are conducting a focus group, survey, or plan to employ statistical methods, please provide answers to the following questions:

The selection of your targeted respondents. Please provide a description of how you plan to identify your potential group of respondents and how you will select them. If the answer is yes, to the first question, you may provide the sampling plan in an attachment.

Administration of the Instrument: Identify how the information will be collected. More than one box may be checked. Indicate whether there will be interviewers (e.g. for surveys) or facilitators (e.g., for focus groups) used.

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